TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
DEPARTMENT OF NURSING

DAILY PHYSICAL EXAMINATION REPORT

Name of Patient: __________Patient X Age: 58 Date of Birth: August 06, 1963

Medical Diagnosis: Stable Anigina Pectoris
Nursing Diagnosis: Stable Angina Pectoris
Assessed by: Mikaela Ramirez Date of Assessment: September 04, 2021 Time: 7:00 am

Assessment
Area N AbN Description of Findings & Interpretation
General Appearance / Facial grimace due to chest pain
Posture Discomfort
Hygiene/Grooming / Normal findings
Nutrition/Diet / Normal Findings
Body Size/Habitus / Normal findings
Height: _____5’7__ / Normal findings
Weight: ____176 lbs___ / Overweight
Supply appropriate data:
 IBW: ___________
 BMI: ____27.6_______
/ Overweight
 IRS: ____________
Behavior / With observable discomfort
LOC / normal
Vital Signs
Temperature: ___36.18*C____ Normal
Pulse Rate: _________
Rhythm: __________
Respiration Rate: __16cpm______ Normal findings
Rhythm: ___________
Blood Pressure: ___160/95mmHg____ / Hypertension
Skin /
Color / Pale skin
Temperature / warm
Turgor / Good skin turger
Texture / Smooth
Integrity / Normal
Unusual Marks / No presence of unusual markings
Rashes, Lesions / No presence of rashes or lesion
Pressure sore: Yes ___ No __/_ / No presence of pressure sore
Site: ___________________
Edema: Yes ____ No _/___ / No presence of edema
Site: _____________________
Type: _____________________
Size/Degree: _______________
Hair / Within normal findings
Texture Oily
Thickness / Equal thickness
Color & Distribution / Equal color and distribution
Hygiene Status / No presence of lice or dandruff
Nails / Normal findings
Color & Shape Symmetrical
Hygiene Status / Nails are cut
Presence of Clubbing / No presence of clubbing
Head / Within normal findings
Shape & Symmetry / Head is round and symmetrical
Unusual swelling / No presence of swelling
Cranial bruit / No presence of bruit

Form No.: TSU-COS-SF- Revision No.: 00 Effectivity Date: June 22, 2016 Page 1 of 6

Assessment
Area N AbN Description of Findings & Interpretation
Eyes / Symmetrical
Size, placement & alignment
Cornea / Normal
Pupils / Normal
 Size (mm)
PERRLA / Normal
Visual Acuity / Normal
Orbital Bruit / Normal
Other Findings: ____sunken
eyes____________
Ear / Within normal findings
Location/Alignment
Pinna, Cannals, Drums / Normal
Hygiene / Normal
Discharge and Odor / No discharge and odor
Hearing Acuity / Normal
Tinnitus / Normal
Vertigo/Dizziness / Normal
Other Findings:
________________
Nose / Within normal range
Shape
Symmetry / Symmetrical
Patency / Normal
Mucosal Integrity / Normal
Epistaxis / Normal
Sinuses / Normal
Other Findings:
________________
Lips / Normal Findings
Integrity
Symmetry / symmetrical
Color / pink
Other Findings:
________________
Mouth
Hygiene / Normal
 Assessme
Area nt Description of Findings & Interpretation
N Ab
N
Chest and Lungs / Within normal range
Shape & Symmetry / symmetrical
 Nipple & Areola / Symmetrical
Number & Condition of Teeth
 Mass/Lump / / Normal No presence of lumps
Gums  Others: __________ / Normal
Mucosal Integrity
Breathing / / Normal Lungs are clear
Tongue  Spontaneity / / Normal Normal
Tonsils  With Ventilator / / Normal No presence of ventilator
Palate  With Tracheostomy / / Normal No presence of tracheostomy
Parotid Gland  Rhythm / / Normal Normal rhythm
Hoarseness  Depth / / normal Normal depth
Other Findings: Effort / Normal
________________Use of Accessory Muscles / Normal findings
Neck / Normal range
Carotid Bruit
a. Intercostals
Neck Veins b. Abdominal / / Normal Normal findings
Thyroid c. Sternocleidomastoid/ / Normal Normal findings
Trachea Rigidity/Tenderness / / Normal Normal findings
d. Trapezius
Mass/BruisesCough / / normal No presence of cough
Other Findings:
Sputum Production: Yes _/_ No: / Normal
________________
__ / Normal
 Amount: _____________ / Consistent
 Consistency: __________ / Color less
 Color: _______________ / No odor
 Odor: _______________
Chest X-ray Result / Normal
Breath Sound (Specify) / Normal Breathing sound
a. Bronchial
b. Crackles
Form No.: TSU-COS-SF- Revision No.: 00/ No presence
Effectivity of tachycardia
Date: June 22, 2016 Page 2 of 6
c. Rhonci / No presence of Rhonci
/ No presence of Whezes
d. Wheezes / No presence of stridor
e. Stridor / No presence of crepitus
f. Crepitus
CTT / Normal
Location: __________
Suction: ___________
/ Normal
Water Level: _______
/ Normal
Quality of Drainage:
___________ / normal
ABG / Normal
Other Findings: / normal
________________
Heart / No history of heart disease
History Normal
With Palpitation
/ Normal
Dyspnea
/ Normal
Rhythm / Normal
Point of Maximal Impulsec(PMI) / Normal
(PMI is felt at 5th ICS at apex
of heart) Specify:
Assessme
Areaa. Heaves nt / Description
Normalof Findings & Interpretation
b. Clicks N Ab / Normal
c. Splitting N / Normal
Abdomen / /Presence of pain
Normal
d. Thrills
Diet: ____________________ / /Non-fat or low-fat/Low
Normal sodium
Mode of Feeding:e. __________
Callops
/ oral
f. Muffles
Shape and Symmetry / normal
Presence of Heart Sounds
Umbilicus Protrusion / normal
a. S1 Sound)
Bowel Sound (Indicate / Normal bowel sound
b. S2 / Loud S2 is heard
c. S3 / Normal
/ A questionable sound was heard
d. S4
Murmurs / normal
a. Systolic
b. Diastolic
  LUQ: __________ / Normal bowel sound
 RUQ: __________ / Normal bowel sound
 LLQ: __________ / Normal bowel sound
 RLQ: __________
Abdominal Bruit / No presence of Abdominal Bruit
Distention
Ascites: Yes: ____ No: ____
Nausea / No presence of nausea
Vomitus/Hematemesis / No vomitus/ Hematemesis noted
Amount: _______________
Consistency: ____________
Color: _________________
Odor: _________________
Frequency: _____________
Drainage Tube / No drainage tube
Abdominal Mass / No presence of abdominal mass
Abdominal Girth: __________ / Normal Abdominal Girth
Other Findings:
________________
Back / Normal findings
 Spine
 Paralumbar
/
Other Findings:
________________
Genitalia / Normal findings
Symmetry / Symmetrical
Presence of Tenderness / No presence of tenderness
Urethral Discharge / No presence discharge
Bleeding / No signs of bleeding
Pelvic Pain / No pelvic pain
LMP: ________________ / Normal
With Dysuria / None
With Flank Pain / None
Nocturia / None
History of Urinary Stone / None
History of Impotence / No history impotence
With Urinary Catheter / No presence of urinary catheter
Urinalysis Finding:
_____________
Peritoneal Dialysis (PD) / No history of peritoneal Dialysis
a. Date Started
b. Incorporation
c. Cycle Exchange
Amount:
_______________
Dwell Time:
____________
Drainage Time:
__________
d. PD Return
Color: __________
Flow: __________
Hemodialysis / No history of hemodialysis
Frequency: ________________
Last HD: __________________
Amount of Fluid Removed:
_____
Next HD: __________________
Place: ____________________
 Form No.: TSU-COS-SF- Revision No.: 00 Effectivity Date: June 22, 2016 Page 4 of 6

Assessme
Area nt Description of Findings & Interpretation
N Ab
N
Rectal Examination / Normal findings
Anal Inspection
With Hemorrhoids: Yes:__ No:__
Normal findings
Location: ______________
Normal findings
Characteristics: _________
Normal findings
Mass Normal findings
Last Bowel Movement:
_________
Characteristic of Stool: / Normal characteristics of stool
__________
Other Findings:
________________
Nodes / Normal findings
Lymphadenopathy
Location
/ Normal findings
a. Cervical R ___ L ___
b. Axillary
c. Inguinal R ___ L ___ / Normal findings
Others ______________ / Normal findings

Extremity / Normal finding in the extremity

Texture
Capillary Refill / Normal Capillary refill
Peripheral Pulse (both sides) / Normal findings
 Carotid
 Radial
 Ulna / Normal findings
 Brachial / Normal findings
 Femoral / Normal findings
 Posterior Tibial / Normal findings
 Dorsalis Pedis / Normal findings
 Popliteal / Normal findings

Clubbing of Fingers / No presence of clubbing

Varicosities / No presence of varicosities
Thrombophlebitis / Normal findings
Cyanosis / No sign of cyanosis
Joints / Normal findings
 Erythema
 Tenderness
 Deformity / No presence of tenderness
/ No presence of swelling
  Swelling
Muscles / Normal findings
 Bulk
 Tone
 Tenderness / Normal findings
/ Normal findings
Ulcerations / No presence of ulcerations
Edema / No presence of edema
Other Findings:
________________

Form No.: TSU-COS-SF- Revision No.: 00 Effectivity Date: June 22, 2016 Page 5 of 6

Assessme
Area nt Description of Findings & Interpretation
N Ab
N
Hematopoietic / Normal findings
Easy Bruisability
Excessive Bleeding / Normal findings
Anticoagulants / Normal findings
Bleeding Profile / Normal findings
Anemia / Normal findings
Hematology Report / Normal findings
Other Findings:
________________
Neurology / Normal findings
Assessment of Cranial Nerves
 CN I (Olfactory)
 CN II (Optic)
 CN III (Oculomotor) / Normal findings
 CN IV (Trochlear) / Normal findings
 CN V (Trigeminal) / Normal findings
 / Normal findings
/ Normal findings
/ Normal findings
/ Normal findings
 CN VI (Abducens) / Normal findings
 CN VII (Facial) / Normal findings
 CN VIII / Normal findings
(Vestibulocochlear) / Normal findings
 and
Motor CNPosture
IX (Glossopharyngeal) / Normal findings
Sensory Perception / Normal findings
Reflexes / Normal findings
a. Indicate Type of
Reflex______
_____________________
___ / Normal findings
b. Pathologic Reflex: Yes__
No__
Other Findings:
_________________
Patient’s ADL / Normal findings
a. Bathing
b. Dressing
c. Elimination / Normal
d. Mobility and Movement / Normal findings
e. Nutrition and Feeding / More on potassium/ less fat and sodium intake

Form No.: TSU-COS-SF- Revision No.: 00 Effectivity Date: June 22, 2016 Page 6 of 6